CCS Case: Acute Pancreatitis — Gallstone

Case: Acute Pancreatitis — Gallstone

Clinical Setup

• Presentation: 45-year-old female with sudden severe epigastric pain radiating to the back, nausea, vomiting, epigastric tenderness, lipase 1200 U/L, tachycardic, mildly hypotensive.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q15min.
   • 2 large-bore IVs, aggressive IV fluid resuscitation: Lactated Ringer’s or Normal saline bolus then 200–250 mL/hr (titrate to vitals/urine output).
   • NPO initially; antiemetics (ondansetron IV).
2. Focused Exam (Minute 1–2):
   • Abdominal exam (tenderness, guarding, Cullen/Grey-Turner signs if severe), lung bases (effusions), volume status.
3. Diagnostics (Minute 2–5):
   • Lipase stat, CBC, CMP (calcium, LFTs, bilirubin), triglycerides, ABG if hypoxic.
   • RUQ ultrasound stat (gallstones, sludge, CBD dilation).
   • Contrast CT abdomen only if diagnosis uncertain or severe/necrotizing course suspected.
4. Therapeutics (Minute 5–15):
   • IV pain control (morphine or fentanyl); IV fluids continued with strict I/O and Foley if unstable.
   • No routine antibiotics unless infected necrosis/cholangitis suspected.
   • If concurrent cholangitis (fever, jaundice, RUQ pain): urgent GI consult for ERCP within 24 hours + broad-spectrum antibiotics.
   • Advance diet early (low-fat) once pain/nausea improve; advance clock in 30–60 min increments.
5. Disposition (Minute 15–20):
   • Admit to floor (mild) or ICU (organ failure, SIRS, hypotension).
   • Cholecystectomy during same admission once pancreatitis resolving (gallstone etiology).
6. Final 2 Minutes:
   • Counsel on alcohol abstinence, low-fat diet, gallstone prevention, smoking cessation.
   • Schedule surgery and GI follow-up; review triglyceride and medication causes.